DIGGING A DEEP HOLE AND JUMPING IN IT: REPEALING THE AFFORDABLE CARE ACT WITH NO VIABLE REPLACEMENT

Let’s say the Republicans, in keeping with numerous campaign promises, repeal the Affordable Care Act (“ACA” or “Obamacare”) as one of the first legislative acts after President-elect Trump takes office. Suppose the Act repealing the ACA says it won’t take affect until the passage of a certain amount of time, e.g., two years. Suppose that on the date the repealer is passed, there are no complete, viable plans acceptable to insurers, providers, insureds, taxpayers, voters and other key players required to bring US health care and health care coverage up to the levels we should expect of a country with the financial wealth and human resources we have at our disposal.

Does this not sound familiar? Is it not like holding the nation’s promises to pay its debts hostage by refusing to raise debt ceilings until certain other legislative changes are made? Is it not like repeated, strung out threats to shut down the entire government if budget concessions are not made? And is it not like digging a deep, deep hole and jumping into it without the slightest clue how to get out.

Well, there are a few clues we have about what might happen if the ACA were to be so repealed.

Is single payer, universal health care in the cards? Set aside the question whether it should be. Unless I’m delusional, it’s just not going to happen in the next two years. So I will not discuss it further in this post.

So what will happen? We should be seeing various players – big players – telling Congress what they want, what they need, what they expect, and what they demand. All manner of lobbyists will weigh on to explain what is required in order for enterprises and groups they represent to remain viable as part of a market-based health care system. Is this bad? Is this evil? Is the influence of lobbyists telling Congress what they think is needed a terrible thing? To my way of thinking, absolutely not. It is inconceivable to me that Congress, without input from industry players, would ever come up with anything that might come close to meeting our nation’s health care needs. Lobbying is essential, but “buying” favor with large campaign contributions is not.

I’m not going to discuss the “demands” listed in the NYT article. Instead, I will share some comments collected in discussions with various friends.

The first comment came from a healthcare provider who wrote:

I think the first thing that I am going to be all over when the new congressional wrecking ball comes in and Trump begins to blast away with all the “through the looking glass” appointees is healthcare. “OK, what are you going to do if you don’t want the Affordable Health Care plan?” Do the same thing and call it Trump Care? Go back to only insuring 19 year olds on their parents plan; reinstating pre-existing condition exclusions? Make more cuts to Medicare and roll back Medicaid? That is, right now, my Rubicon, but of course, something more outrageous could come up before that–my mind is open to a potential catastrophe that could “trump” that one.

Some passion mixed with fear there. This was followed by several additional statements of concern from private citizens.

The next comment came from another provider who stated:

I supported the ACA initially as a practicing physician but was always concerned with financing. Now as a result of the implementation private pay insurance deductibles have gone through the roof and Obamacare is cumbersome to work with and docs can’t afford to add the personnel to keep track of it. There is only one insurer as of this Dec 31 left in Texas and it is terrible. The upshot is that patients have insurance but only catastrophic, so yes this needs to be globally re evaluated and no the sky is not going to fall in.

A candid expression that the ACA is not working in Texas coupled with the optimistic view that “the sky is not going to fall in.”

Next came a piece mixing politics and personal experience.

I was with [name omitted] today at his cardiologist’s office and he [the cardiologist, I believe] said the same thing… I’m not saying any program is perfect or even good, but I think it is beneficial to have youngsters insured until 26 and coverage for previous conditions. Who is going to be working on saving the pluses and improving what doesn’t work? According to most doctors I have talked with, their burden is increased, they can’t keep up with paper work and the insurance providers are getting even more wealthy and providing less service. We have to have a safety net for citizens who can’t afford basic health care. We pay the largest part of our incomes not for housing or good, but for healthcare!

That comment from someone I would consider center-left Democrat.

From a friend I would describe as a center-right independent with strong Republican tendencies came this testimonial:

ACA has improved some points in insurance coverage for everyone. More preventative coverage is fully covered for all. Mammograms and colon tests for example. No penalty for preexisting. And college age dependents. In 1986 my dad’s company changed insurance carriers. Both parents had cancer. Bam! No coverage. Not their fault and nothing they could do. They died owing thousands of dollars in medical costs. That can’t happen today. At age 24 my son had cancer. Fortunately he was diagnosed and cancer removed 2 months before his birthday and end of coverage. That can’t happen today. However, my daughter has dealt with ACA coverage and the cost is high both premium and deductible with coverage minimal.

This was followed a testimonial plus editorial by the same friend I consider to be a center-left Democrat.

Your scary stories are personal evidence of the failure of the insurance agencies to deal with its insured fairly. My dad spent the last five years of his life on dialysis. He ran through $1 million worth of insurance and then had to pay three times a week for his dialysis. At the time that was about $12,000 a week. He decided to go to two times a week for dialysis and passed away within a year of the end of his insurance. I am sure he did did not have the will to go on living. My son had a previous condition that was addressed when he was in college. During his post college first job, the problem reappeared. He needed surgery which was not covered because it was a previous condition. He started his professional life thousands of dollars in debt. As DT says, “so unfair.”

She also added: “Being without any healthcare or inadequate health care is a stress no one needs while fighting a serious disease.”

The following post was mine, quickly written, as is this blog post. I have edited it lightly.

Just saw the stream of messages. One quick comment. There are two issues that can be decoupled although they are not totally independent. The first is: What should be covered by health care insurance? The second is: What is the fair, equitable, and politically acceptable way to finance the insurance?

Any form of insurance is based on estimates of and assumptions of risk. If the population is made healthier, or lower cost preventative health care replaces expensive acute care treatment of conditions that could have been prevented, total costs decrease. That’s in the long term. But insurance companies, especially start-ups, can’t always deal with the long-term and even experienced, established companies may encounter problems in predicting what will happen short-term.

Many insurance companies setting rates under Obamacare made some seriously incorrect assumptions. They apparently did not realize that healthy people would think themselves invincible and remove themselves from the insurance pool. Further, insurance companies have historically wanted lower risk (“preferred risk”) policy holders. To get the best life insurance, for example, you start when you are young and healthy. One day, you want additional insurance. You are asked to take some medical tests. You learn you have high blood pressure. Good for you. That insurance company test may have added years to your life. But you will pay more for the additional life insurance if you are able to get.

A series of factors, some of which were inserted into the Obamacare legislation by people who wanted it to fail, have led to the kinds of issues [name deleted] described. Others were built into the legislation by Obamacare proponents to avoid political backlash. As is often the case with ambitious new legislation, the legislation was flawed. Companies believing they could write sound policies base don what they though would happen under the legislation cratered. Plans worked in some states and not others.

Now, why so much paperwork? Four words: waste, fraud, and abuse. Two additional words: cost control.

Why high deductibles and copays? To reduce premiums and provide incentives to insureds not to seek unnecessary health care.

All these things are manageable, if the insurance companies apply sound actuarial principles to reasonable assumptions. The problem has been that the assumptions were made in unstable political and legal conditions and were based on incomplete data. Bad assumptions made some of the companies’ initial Obamacare policies unsustainable money losers, or so they say.

Where is the safety net for the first tier insurers? Two come to mind: government subsidies and the purchase reinsurance. I am not sure how either have worked under the ACA. Certainly, the Republican governors who thwarted Medicaid expansion in their states added to the problems, although they may say otherwise.

Anyway, there can be fixes to Obamacare or a replacement that works better. The problem is that we haven’t yet seen reasonable proposals the public can understand.

Public single payer? Great concept but it’s not likely to happen in my lifetime and arguably has serious drawbacks as well as major benefits. I would like to hear from the Democrats what they propose, and it had better not be just to tinker around the edges.

We need a program that works for insureds, providers, insurers, and taxpayers. ACA – a great step forward. Republican obstructionism to make Obama look bad – a willful embrace of evil. (Sorry for this vehemence, but we have to recognize that this is not just a dispute between policy wonks on details. This was calculated political sabotage arguably in retaliation for the Republicans having been given little input into the drafting and passage of the ACA. (Okay, it was based on the Romney health plan in Massachussetts, but let’s forget that inconvenient truth.) More some other day.

We will see what Trump and the Republican leadership propose. Maybe some of it will have merit. Right now, however, the burden is squarely on the Democrats because there is little evidence so far that the Republicans will act in good faith to solve any problems other than those experienced by citizens in the higher end of the wealth/income spectrum.

This drew a strong response from one of my left-of-center friends. He wrote:

Until we, as a nation, grow up and design a uniquely American form of the single-payer model it’s ALL tinkering around the edges. No plan likely to be offered by republicans will help anyone who actually needs the help. I hate to sound so certain and negative but I can only go by what I’ve seen so far. We must take the profit motive out of healthcare. The republicans want themselves and their peers to profit off everything the government does. At what point is the health of everyone in the greater community deemed more important than the interests of insurance company stockholders? The further in the future we place the answer the less future generations will think of us.

This response drew a number of thumbs up whereas my comment drew none and was followed by another comment from the provider who first raised the issue in our discussion.

Health care HAS to become a part of the infrastructure of society. It can not continue to be looked at as something people have to buy. I worked for a behavioral health insurance company for years. I have many stories to tell about how “bean counters” subvert almost any contract to maximize company profits and subject policy holders to unexpected financial catastrophes.

For several years it has been a Medicare regulation that companies can not refuse payment of care at facilities that are not contracted with the insurance company (Medicare replacement policies) if the attending physician does not agree that the care no longer meets medical necessity. However, the company lawyers decided the “work around” there was not to review on these out of network cases at all while the patient was in treatment, and to only review them retrospectively. This resulted in many instances where patients would find themselves facing 50, 60, 100 thousand dollar bills months after discharge when their claims were denied. They had no informed choice as to whether to continue treatment that would not be paid for until it was too late.

For six years I protested this policy and brought statistics to middle and upper management. I pointed out that their slogan of “Making people healthier” was being undermined by this capitulation to their bottom line. I really don’t know how it happened, but one day, over a year ago, they changed the policy back to reviewing as treatment was given. Now, at least, people have that information beforehand. But that, and many other, instances told me unequivocally that insurance is never going to be friendly to people’s health or their financial lives. It will always be the stockholders who are considered first.

It is no wonder that our health care is the most expensive in the world, but the United States is ranked no higher than 16th in being healthy. My counterpart therapists in Germany, for one example, never worry about paper work, “pass through visits,” or taking time for medical necessity review phone calls. Any German gets 52 mental health sessions per year with any licensed therapist, no questions asked. All Germans need to do is say, “I need to talk to a psychotherapist.” It is their right as a German. That is the kind of practice that any liberal democracy needs to embrace if it views itself as a society, and not just a collection of individuals.

So here we have quite a mix of views.

My final comment and current opinion:

I generally agree with the comments but continue to believe that any move to single payer, universal health coverage as an entitlement will not be well-received by Congress – certainly not while the Republicans are held hostage by their most extreme members, without whose votes they would not get elected.

I take no credit for the outstanding input provided to me by the members of our discussion group. Why did they speak out? Here’s one reason provided:

My point is that there has been some positive outcome with ACA that we all have or could benefit from. That includes Medicare coverage also. However, there is lots of room for improvement. I used my personal experiences because they are true factual examples.

Please feel free to comment, if you can figure out how, on this blog or on Twitter. My Twitter handle is @wmschur.